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Importance: Supplementing potassium in an effort to maintain high-normal serum concentrations is a widespread strategy used to prevent atrial fibrillation after cardiac surgery (AFACS), but is not evidence-based, carries risks, and is costly., Objective: To determine whether a lower serum potassium concentration trigger for supplementation is noninferior to a high-normal trigger., Design, Setting, and Participants: This open-label, noninferiority, randomized clinical trial was conducted at 23 cardiac surgical centers in the United Kingdom and Germany. Between October 20, 2020, and November 16, 2023, patients with no history of atrial dysrhythmias scheduled for isolated coronary artery bypass grafting (CABG) surgery were enrolled. The last study patient was discharged from the hospital on December 11, 2023., Interventions: Patients were randomly assigned to a strategy of tight or relaxed potassium control (only supplementing if serum potassium concentration fell below 4.5 mEq/L or 3.6 mEq/L, respectively). Patients wore an ambulatory heart rhythm monitor, which was analyzed by a core laboratory masked to treatment assignment., Main Outcomes and Measures: The prespecified primary end point was clinically detected and electrocardiographically confirmed new-onset AFACS in the first 120 hours after CABG surgery or until hospital discharge, whichever occurred first. All primary outcome events were validated by an event validation committee, which was masked to treatment assignment. Noninferiority of relaxed potassium control was defined as a risk difference for new-onset AFACS with associated upper bound of a 1-sided 97.5% CI of less than 10%. Secondary outcomes included other heart rhythm-related events, clinical outcomes, and cost related to the intervention., Results: A total of 1690 patients (mean age, 65 years; 256 [15%] females) were randomized. The primary end point occurred in 26.2% of patients (n = 219) in the tight group and 27.8% of patients (n = 231) in the relaxed group, which is a risk difference of 1.7% (95% CI, -2.6% to 5.9%). There was no difference between the groups in the incidence of at least 1 AFACS episode detected by any means or by ambulatory heart rhythm monitor alone, non-AFACS dysrhythmias, in-patient mortality, or length of stay. Per-patient cost for purchasing and administering potassium was significantly lower in the relaxed group (mean difference, $111.89 [95% CI, $103.60-$120.19]; P <.001)., Conclusions and Relevance: For AFACS prophylaxis, supplementation only when serum potassium concentration fell below 3.6 mEq/L was noninferior to the current widespread practice of supplementing potassium to maintain a serum potassium concentration greater than or equal to 4.5 mEq/L. The lower threshold of supplementation was not associated with any increase in dysrhythmias or adverse clinical outcomes., Trial Registration: ClinicalTrials.gov Identifier: NCT04053816.

Background:  Composite T-grafts between left internal mammary artery (LIMA) and radial artery (RA) are a common concept in complete arterial myocardial revascularization. The aim of the present study was to investigate whether the use of the great saphenous vein (SV) instead of RA leads to comparably good results in terms of outcome in this context., Methods:  Patients who underwent myocardial revascularization with a T-graft using RA or a segment of SV to the right coronary artery or circumflex artery between the beginning of 2014 and the end of 2019 at the Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein, Campus Kiel were included. To minimize surgical variation, only patients were observed by a single senior surgeon in the department. Exclusion criteria were previous cardiac surgery, preoperative extracorporeal circulatory support, off-pump surgery, additional aortocoronary bypasses, and cardiac combination procedures., Results:  A total of 115 patients were studied. In 55 patients, the T-graft was placed between the LIMA and SV, and in 60 patients, the T-graft was placed between the LIMA and RA. Patients in the SV group were older (70.6 ± 7.8 vs. 58.5 ± 10.0 years; p  < 0.001), suffered more frequently from non-ST elevation myocardial infarction (12.7 vs. 1.7%; p  = 0.027), arterial hypertension (83.6 vs. 61.7%; p  = 0.009), and atrial fibrillation (18.2 vs. 1.7%; p  = 0.003). They were less likely to be active smokers (16.4 vs. 38.3%; p  = 0.009) and less likely to have a history of variceal surgery (0 vs. 15.0%; p  = 0.003). Calcification of the ascending aorta was also found more frequently in the saphenous group (18.2 vs. 3.3%, p  = 0.009). Operative times and number of distal anastomoses did not differ significantly between the two groups. Postoperative deliriums (16.7 vs. 5.0%; p  = 0.043) were observed more frequently in venous patients. Wound healing disorders of the leg (11.1 vs. 0%; p  = 0.011) did only occur in SV group and wound infections of the arm only in the RA group. Complete follow-up was achieved in 74.8% of cases. Median follow-up was 60.3 (39.6; 73.2) months. Serious adverse cardiac-cerebral events (19.0 vs. 22.7%; p  = 0.675) and mortality (14.5 vs. 6.7%; p  = 0.167) did not differ significantly between the groups at follow-up. Myocardial infarction (0 vs. 2.5%; p  = 1.000) and stroke (0 vs. 7.5%; p  = 0.245) were observed exclusively in RA group. Percutaneous coronary intervention was required in single patients of RA group (0 vs. 15.0%; p  = 0.028). No patient from either group underwent repeat coronary artery bypass grafting (CABG). The patients of SV group had angiographically competent grafts and open anastomoses. Graft failure was noted in a single patient in RA group, in which case both grafts and native coronary vessels were stented. Kaplan-Meier analysis revealed no significant survival disadvantage for SV group compared with RA group., Conclusion:  CABG with a composite T-graft between LIMA and a segment of SV may be comparable to bypass surgery with a composite T-graft between LIMA and RA. This might be true in terms of morbidity and mortality over an intermediate-term observation period. The results of our studies give rise to the hypothesis that the decision not to perform aortic bypass anastomosis may be more important than the choice of graft material., Competing Interests: None declared., (Thieme. All rights reserved.)

Background: Atrial Fibrillation After Cardiac Surgery (AFACS) occurs in about one in three patients following Coronary Artery Bypass Grafting (CABG). It is associated with increased short- and long-term morbidity, mortality and costs. To reduce AFACS incidence, efforts are often made to maintain serum potassium in the high-normal range (≥ 4.5mEq/L). However, there is no evidence that this strategy is efficacious. Furthermore, the approach is costly, often unpleasant for patients, and risks causing harm. We describe the protocol of a planned randomized non-inferiority trial to investigate the impact of intervening to maintain serum potassium ≥ 3.6 mEq/L vs ≥ 4.5 mEq/L on incidence of new-onset AFACS after isolated elective CABG., Methods: Patients undergoing isolated CABG at sites in the UK and Germany will be recruited, randomized 1:1 and stratified by site to protocols maintaining serum potassium at either ≥ 3.6 mEq/L or ≥ 4.5 mEq/L. Participants will not be blind to treatment allocation. The primary endpoint is AFACS, defined as an episode of atrial fibrillation, flutter or tachycardia lasting ≥ 30 seconds until hour 120 after surgery, which is both clinically detected and electrocardiographically confirmed. Assuming a 35% incidence of AFACS in the 'tight control group', and allowing for a 10% loss to follow-up, 1684 participants are required to provide 90% certainty that the upper limit of a one-sided 97.5% confidence interval (CI) will exclude a > 10% difference in favour of tight potassium control. Secondary endpoints include mortality, use of hospital resources and incidence of dysrhythmias not meeting the primary endpoint (detected using continuous heart rhythm monitoring)., Discussion: The Tight K Trial will assess whether a protocol to maintain serum potassium ≥ 3.6 mEq/L is non inferior to maintaining serum potassium ≥ 4.5 mEq/L in preventing new-onset AFACS after isolated CABG., Trial Registration: ClinicalTrials.gov Identifier: NCT04053816. Registered on 13 August 2019. Last update 7 January 2021., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Campbell et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Recent randomized controlled trials have sparked debate about the optimal treatment of patients suffering from left main coronary artery disease. The present study analyzes outcomes of left main stenting versus coronary bypass grafting (CABG) in a nationwide registry in patients with chronic coronary syndrome (CCS)., Methods: All cases suffering from CCS and left main coronary artery disease treated either with CABG or stent, were identified within the database of the German bureau of statistics. Logistic or linear regression models were used with 20 baseline patient characteristics as potential confounders to compare both regimens., Results: In 2018, 1318 cases with left main stenosis were treated with CABG and 8,920 with stent. Patients assigned for stenting were older (72.58 ± 9.87 vs. 68.63 ± 9.40, p < 0.001) and at higher operative risk, as assessed by logistic EuroSCORE (8.77 ± 8.45 vs. 4.85 ± 4.65, p < 0.001). After risk adjustment, no marked differences in outcomes were found for in-hospital mortality and stroke (risk adjusted odds ratio (aOR) for stent instead of CABG: aOR mortality: 1.08 [95% CI 0.66; 1.78], p = 0.748; aOR stroke: 0.59 [0.27; 1.32], p = 0.199). Stent implantation was associated with a reduced risk of relevant bleeding (aOR 0.38 [0.24; 0.61], p < 0.001), reduced prolonged ventilation time (aOR 0.54 [0.37 0.79], p = 0.002), and postoperative delirium (aOR 0.16 [0.11; 0.22], p < 0.001). Furthermore, stent implantation was associated with shorter hospital stay (- 6.78 days [- 5.86; - 7.71], p < 0.001) and lower costs (- €10,035 [- €11,500; - €8570], p < 0.001)., Conclusion: Left main stenting is a safe and effective treatment option for CCS-patients suffering from left main coronary artery disease at reasonable economic cost. Coronary artery bypass grafting versus stent implantation in patients with chronic coronary syndrome and left main disease: insights from a register throughout Germany. All cases with chronic coronary syndrome and left main stenosis treated in 2018 in Germany either with left main stenting or coronary bypass grafting were extracted from a nation-wide database. In-hospital outcomes were compared after logistic regression analysis., (© 2021. The Author(s).)

Purpose: To explore the effect of undergoing coronary artery bypass grafting on sexual quality of life as an integral part of patients' health-related quality of life., Methods: This cross-sectional study included 265 men ages 18 to 60 years (median age, 55) who underwent coronary artery bypass grafting 1 to 5 years before the study. Standardized questionnaires were implemented to evaluate participant pre- and postoperative sexual quality of life and the quality of counseling provided to patients., Results: Among the patients, 77% were in a steady relationship. The general health score was 5.5 ± 2.8 (mean ± standard deviation) preoperatively and 6 ± 2.2 at follow-up (P = .01). No sexual counseling was given to 83% and 77% of the patients pre- and postoperatively, respectively. The mean sexual satisfaction score dropped from 6.5 ± 2.6 preoperatively to 4.7 ± 3 postoperatively (P < .001). The decline in sexual intercourse frequency and masturbation frequency was significant (P < .001 and P = .006, respectively). Linear regression analysis showed that general health status (P = .008), higher-quality counseling (P = .027), and preoperative sexual quality of life (P < .001) correlated positively with sexual quality of life, whereas sternal pain (P < .001), erectile dysfunction (P < .001), and fear of excessive cardiac burden (P < .001) correlated negatively., Conclusions: Middle-aged men experience decreased sexual quality of life after coronary artery bypass grafting. Preoperative sexual quality of life, general health, and higher-quality counseling positively affect postoperative sexual quality of life, whereas sternal pain, fear, and erectile dysfunction play a negative role. Pre- and postoperative care guidelines should be improved. Further prospective large cohort studies for males and females are required.

Postoperative coronary angiography offers the basis for prompt management of ischemic complications after coronary artery bypass grafting (CABG). Little is known about the effects of postoperative angiography on renal function. The current study aims to assess the incidence and risk factors for acute kidney injury (AKI) following postoperative coronary angiography. A total of 221 CABG patients (mean age, 67 ± 8 years) underwent postoperative coronary angiography due to perioperative myocardial infarction (PMI). AKI was defined according to the KDIGO criteria. Logistic regression analyses were performed to find out risk factors responsible for AKI and to ascertain significant associations between AKI and in-hospital death. Mean delay from CABG operation to postoperative angiography was 1.4 ± 1.0 days. AKI occurred in 79/221 (36%) patients. Mean serum-creatinine (sCr) values peaked on the first day after the angiography and reached the lowest level at the fourth day. In the multivariable analysis, the following variables were independent predictors for AKI: postoperative peak values of CK-MB (p = 0.049, OR 1.03, 95% CI 1.00-1.06 per 10 U/l), EuroSCORE I (p = 0.011, OR 1.18, 95% CI 1.04-1.35), and AKI before re-angiography (p = 0.004, OR 3.50, 95% CI 1.51-8.16), whereas a delayed angiography (p = 0.031, OR 0.69, 95% CI 0.49-0.97) was protective against AKI. Patients with post-angiography AKI had a significantly higher mortality after multivariable adjustment than patients without AKI (15.5% vs. 2.11%, p = 0.001, OR 5.42, 95% CI 1.35-21.75). Over one-third of patients who undergo postoperatively angiography develop AKI. The occurrence of AKI must be considered during the decision-making prior to coronary angiography, especially in patients presenting the identified risk factors for AKI.

Background: From the results of a previous study, it remained to be investigated if a perioperative rise of few tested coagulation and inflammation markers is caused by conventional cardiopulmonary bypass (CPB) itself or rather by direct recirculation of pericardial fluids., Methods: Forty-eight patients operated on with conventional CPB for myocardial revascularization were randomized either for direct recirculation of pericardial suction fluids or for cell saving (CS)., Results: Thrombin-antithrombin complexes showed lower values intraoperatively in the CS group ( p  < 0.0001), and D-dimers tended to remain lower at intensive care unit arrival ( p  = 0.095). Tests of inflammation markers were less meaningful., Conclusion: Direct recirculation of pericardial fluids rather than conventional CPB itself causes major intraoperative changes of some coagulation markers. Pericardial blood loss with direct recirculation should be kept to a minimum to avoid unnecessary activation of coagulation. Inflammation markers need further investigations., Competing Interests: The authors have no disclosure or conflict of interest., (Georg Thieme Verlag KG Stuttgart · New York.)

Background:  Crystalloid priming is a cost-effective, free from immunological reactions, and independent from human plasma delivery. However, there is some debate on the negative impact of low plasma colloid pressure and higher incidence of systemic inflammatory response syndrome (SIRS). The aim of the study was to rule out any adverse effects of crystalloid priming on the postoperative outcome., Methods:  We investigated 520 consecutive patients, including emergencies, who had isolated on-pump coronary artery bypass grafting in 2009 by retrospective analysis in our clinic. Crystalloid priming ( n  = 294) was introduced as an alternative to albumin ( n  = 226). Reviewing patient charts and IT-based data generated a dataset of perioperative parameters., Results:  There were no differences with respect to demographical data and preexisting comorbidities between both groups. Despite equal perfusion times, more volume had to be substituted during extracorporeal circulation following crystalloid priming. However, this did not influence the inhospital outcomes. According to the definition of the "Sepsis-3 Guidelines," the incidence of SIRS was similar. There was no difference in the need for a vasopressor treatment, and only transient higher serum lactate levels were found in the crystalloid group. The incidence of neurologic and organ-related adverse events, as well as 30-day mortality was comparable., Conclusion:  The use of crystalloid priming is safe in coronary artery bypass grafting surgery in adults. However, there might be a greater need for crystalloid fluids during surgery., Competing Interests: All authors confirm that they have no conflict of interest Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors., (Georg Thieme Verlag KG Stuttgart · New York.)

Background:  Patients receiving arterial grafts have superior late survival after coronary artery bypass graft (CABG) surgery. The aim of our study was to evaluate the mid- and long-term results of total arterial (TA) revascularization in the elderly., Methods:  Between January 2005 and December 2012, a retrospective study on age-, gender-, and EuroSCORE-matched patients aged 70 years and older was performed. Altogether, 356 patients who received isolated CABG were assigned to either TA group or control (CON) group., Results:  No significant differences were noted in regard to preoperative risk factors. The number of distal anastomoses was significantly higher in the CON group (3.6 ± 0.6 vs. 2.9 ± 0.8; p  < 0.001). Postoperatively, no significant differences were noted in regard to morbidity or mortality. There were no significant differences in mortality rate at 1 year (5.6 vs. 5.2%; p  = 0.98), or 5 years (9.0 vs. 12.1%; p  = 0.39) between both groups. However, the TA group was associated with significantly higher rate of event-free survival ( p  = 0.017)., Conclusion:  This study suggests that TA revascularization is an effective procedure. Lower rates of late cardiac events encourage the use of this concept for the elderly., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: While coronary artery bypass grafting remains the standard treatment of complex multivessel coronary artery disease, the advent of peripheral ventricular assist devices has enhanced the safety of percutaneous coronary intervention. We therefore evaluated the safety in terms of inhospital outcome comparing protected high-risk percutaneous coronary intervention with the Impella 2.5 device and coronary artery bypass grafting in patients with complex multivessel coronary artery disease., Methods: This retrospective study included patients with complex multivessel coronary artery disease (SYNTAX score >22) undergoing either coronary artery bypass grafting before the implementation of a protected percutaneous coronary intervention programme with a peripheral ventricular assist device or protected percutaneous coronary intervention with the Impella 2.5 device following the start of the programme. The primary endpoint consisted of inhospital major adverse cardiac and cerebrovascular events. The combined secondary endpoint included peri and post-procedural adverse events., Results: A total of 54 patients (mean age 70.1±9.9 years, 92.6% men) were enrolled in the study with a mean SYNTAX score of 34.5±9.8. Twenty-six (48.1%) patients underwent protected percutaneous coronary intervention while 28 (51.9%) patients received coronary artery bypass grafting. The major adverse cardiac and cerebrovascular event rate was numerically higher in the coronary artery bypass grafting group (17.9 vs. 7.7%; P =0.43) but was not statistically significant. The combined secondary endpoint was not different between the groups; however, patients undergoing coronary artery bypass grafting experienced significantly more peri-procedural adverse events (28.6 vs. 3.8%; P <0.05)., Conclusion: Patients with complex multivessel coronary artery disease undergoing protected percutaneous coronary intervention with the Impella 2.5 device experience similar intrahospital major adverse cardiac and cerebrovascular event rates when compared to coronary artery bypass grafting. Protected percutaneous coronary intervention represents a safe alternative to coronary artery bypass grafting in terms of inhospital adverse events.

Background Coronary artery bypass grafting for acute coronary syndrome complicated by cardiogenic shock ( CS ) is associated with a high mortality. This registry study aimed to distinguish between early surgical outcomes of CS patients with non- ST -segment-elevation myocardial infarction ( NSTEMI ) and ST -segment-elevation myocardial infarction ( STEMI ). Methods and Results Patients with NSTEMI (n=1218) or STEMI (n=618) referred for coronary artery bypass grafting were enrolled in a prospective multicenter registry between 2010 and 2017. CS was present in 227 NSTEMI (18.6%) and 243 STEMI patients (39.3%). Key clinical end points were in-hospital mortality ( IHM ) and major adverse cardiocerebral events ( MACCEs ). Predictors for IHM and MACCEs were identified using multivariable logistic regression analysis. STEMI patients with CS were younger, had a lower prevalence of diabetes mellitus and multivessel disease, and exhibited higher myocardial injury (troponin 9±17 versus 3±6 ng/mL) before surgery compared with patients with NSTEMI ( P<0.05). Emergency coronary artery bypass grafting was performed more often in STEMI (58%) versus NSTEMI (40%; P=0.002). On-pump surgery with cardioplegia was the preferred surgical technique in CS . IHM and MACCE rates were 24% and 49% in STEMI patients with CS and were higher compared with NSTEMI ( IHM 15% versus MACCE 34%; P<0.001). Predictors for IHM and MACCE in CS were a reduced ejection fraction and a higher European System for Cardiac Operative Risk Evaluation score. Conclusions Surgical revascularization in NSTEMI and STEMI patients with CS is associated with a substantial but not prohibitive IHM and MACCE rate. Worse early outcomes were found for patients with STEMI complicated by CS compared with NSTEMI patients.

Introduction: The recommended minimum activated clotting time (ACT) level for cardiopulmonary bypass (CPB) of 480 seconds originated from investigations with bubble oxygenators and uncoated extracorporeal circulation (ECC) systems. Modern minimal invasive ECC (MiECC) systems are completely closed circuits containing a membrane oxygenator and a tip-to-tip surface coating. We hypothesized that surface coating and the "closed-loop" design allow the MiECC to safely run with lower ACT levels and that an ACT level of 300 seconds can be safely applied without thromboembolic complications. The aim of this study was to investigate the potential risks during application of reduced heparin levels in patients undergoing coronary surgery., Methods: In this study, 68 patients undergoing coronary artery bypass grafting with MiECC were randomized to either the study group with an ACT target of 300 seconds or the control group with an ACT of 450 seconds. All other factors of MiECC remained unchanged., Results: The study group received significantly less heparin and protamine (heparin [international units] median [min-max], Red&#95;AC: 32,800 [23,000-51,500] vs. Full&#95;AC: 50,000 [35,000-65,000] p  < 0.001; protamine [international units], Red&#95;AC: 18,000 [10,000-35,000] vs. Full&#95;AC: 30,000 [20,000-45,000] p  < 0.001). The ACT in the study group was significantly lower at the start of MiECC (mean ± standard deviation: study group 400 ± 112 vs. control group 633 ± 177; p  < 0.0001). Before termination of CPB the ACT levels were: study group 344 ± 60 versus control group 506 ± 80. In both groups, the values of the endogenous thrombin potential (ETP) decreased simultaneously. None of the study participants experienced thromboembolic complications., Conclusion: Since no evidence of increased thrombin formation (ETP) was found from a laboratory standpoint, we concluded that the use of MiECC with a reduced anticoagulation strategy seems possible. This alternative anticoagulation strategy leads to significant reduction in dosages of both heparin and protamine. We can confidently move forward with investigating this anticoagulation concept. However, to establish clinical safety of ACT below 300 seconds, we need larger clinical studies., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: This study reviewed our experience with coronary artery (CA) malperfusion secondary to type A aortic dissection., Methods: Between 2002 and 2017, 76 patients presented with CA malperfusion, with a dissection flap limited to the aorta in the region of the coronary ostium (type A lesion) in 26 (34%), with a dissection flap involving the CA itself (type B lesion) in 32 (42%), or with complete avulsion of the CA (type C lesion) in 18 (24%)., Results: Ostial repair was successfully performed in 23 type A patients (88%), in 20 type B patients (63%), and in no type C patient (0%). CA bypass grafting was performed when antegrade cardioplegia could not be applied in all 18 type C patients (100%) and in 5 type B patients (16%) because of a primary entry at the coronary ostium and in 7 patients (type A: 3 patients [12%], type B: 4 patients [13%]) with evidence of CA disease (p < 0.001). Perioperative mortality in patients with CA malperfusion was high (18 patients [24%]), but there was no difference in short-term (p = 0.153) or long-term survival (log-rank p = 0.542). Also, a landmark analysis showed equal survival of discharged patients with and without CA malperfusion (log-rank p = 0.645)., Conclusions: We recommend CA bypass grafting in patients with type C lesions or in patients with underlying CA disease for optimal delivery of cardioplegia and ostial pledgetted suture repair in patients with type A lesions or type B lesions when the administration of antegrade cardioplegia is successful., (Copyright © 2019 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Although associations between cardiovascular diseases and cognitive impairment are well known, the impact of cognitive performance on the success of patient education as a core component of cardiac rehabilitation remains insufficiently investigated so far., Design: Prospective observational study in two inpatient cardiac rehabilitation centres between September 2014 and August 2015 with a follow-up six months after cardiac rehabilitation., Method: At admission to and discharge from cardiac rehabilitation, the cognitive performance of 401 patients (54.5 ± 6.3 years, 80% men) following an acute coronary syndrome and/or coronary artery bypass graft was tested using the Montreal Cognitive Assessment. Patients' disease-related knowledge was determined using a quiz (22 items for medical knowledge and 12 items for healthy lifestyle and behaviour) at both times and at follow-up. The change in knowledge after cardiac rehabilitation was analysed in multivariable regression models. Potentially influencing parameters (e.g. level of education, medication, cardiovascular risk factors, coronary artery bypass graft, comorbidities, exercise capacity) were considered., Results: During cardiac rehabilitation, disease-related knowledge was significantly enhanced in both scales. At follow-up, the average level of medical knowledge was significantly reduced, while lifestyle knowledge remained at a stable level. The maintenance of knowledge after cardiac rehabilitation was predominantly predicted by prior knowledge, cognitive performance at discharge from cardiac rehabilitation and, in the case of medical knowledge, by coronary artery bypass graft., Conclusion: Patient education in cardiac rehabilitation led to enhanced disease-related knowledge, but the maintenance of this essentially depended on patients' cognitive performance, especially after coronary artery bypass graft. Therefore, patient education concepts in cardiac rehabilitation should be reconsidered and adjusted as needed.

Background: Individualized heparin management (IHM) uses heparin dose-response curves to improve hemostasis management during cardiac surgery as compared with activated clotting time-based methods., Objectives: IHM was compared with conventional hemostasis management (CHM) in a randomized, prospective study (ID DRKS00007580)., Methods: One-hundred and twenty patients undergoing multivessel coronary artery bypass grafting (CABG) were enrolled. Heparin and protamine consumption, blood losses, blood transfusions and administration of hemostatic agents were recorded. Time courses of platelet counts and of coagulation parameters were determined. Coagulation was analyzed at intensive care unit (ICU) arrival by thromboelastometry., Results: IHM patients received significantly lower initial heparin doses (289.3IU kg(-1) [interquartile range (IQR) 221.5-376.2 IU kg(-1) ] versus 350.5 IU kg(-1) [IQR 346.8-353.7 IU kg(-1) ], P < 0.0001) but similar total heparin doses (418.5 IU kg(-1) [IQR 346.9-590.5 IU kg(-1) ] versus 435.8 IU kg(-1) [IQR 411.7-505.1 IU kg(-1) ]). IHM patients received significantly less protamine, resulting in protamine/total heparin ratios of 0.546 [IQR 0.469-0.597] versus 0.854 [IQR 0.760-0.911] in CHM patients (P < 0.0001). Activated partial thromboplastin time (50.5 s [IQR 40.0-60.0 s] versus 37.0 s [IQR 33.0-40.0 s], P < 0.0001), activated clotting time (136 s [IQR 129.0-150.5 s] versus 126.5 s [IQR 120.3-134.0 s], P = 0.0002) and INTEM clotting times (215 s [IQR 192-237] versus 201 s [IQR 191-216 s], P = 0.0397) were significantly longer in IHM patients than in CHM patients at ICU arrival, with no difference in prothrombin time (P = 0.538). IHM patients lost significantly more blood within 12 h postoperatively (420 mL [IQR 337.5-605.0 mL] versus 345 mL [IQR 230.0-482.5 mL], P = 0.0041), and required significantly more hemostatic agents to control bleeding. Red blood cell transfusion requirements and time courses of platelet counts did not differ between groups., Conclusions: Multivessel CABG patients did not benefit from IHM in comparison with our established protocol based on activated clotting time., (© 2015 International Society on Thrombosis and Haemostasis.)

Objectives: Cardiac surgical procedures carry a high risk of perioperative bleeding. Surgical sealants are often used to prevent suture line bleeding. PreveLeak™ is a surgical sealant composed of bovine serum albumin, a polyaldehyde cross-linker, and other components that forms a soft, flexible, water-tight, mechanical seal that is biocompatible and bioresorbable., Methods: A prospective, multicentre study evaluated PreveLeak use in 44 subjects undergoing 63 cardiac procedures, primarily coronary artery bypass grafting (n = 23/63, 36.5%) and aortic valve replacement (n = 19/63, 30.2%). PreveLeak was applied to 127 suture lines and the time to sealing evaluated upon clamp release. The primary safety endpoint was the incidence of significant bleeding, infections, neurological deficits and immune/inflammatory allergic responses within 6 weeks post-treatment; subjects were followed for 3 months., Results: Immediate sealing was achieved at all sites in 42 of 44 subjects (95.5%) and 125 of 127 treatment sites (98.4%). There were nine primary safety events: eight infections and one transient neurological deficit. Most adverse events were mild (n = 46/71, 64.8%) or moderate (n = 18/71, 25.4%) in severity. One adverse event (transient vasospasm) was considered possibly sealant-related. One death occurred due to a cardiac arrest., Conclusions: PreveLeak prevented bleeding at 98.4% of treated sites and was well tolerated; adverse events were consistent with those commonly observed in subjects undergoing surgical procedures. These results compared favourably with published studies of other sealants. The observed prevention of bleeding is clinically important in cardiac surgical patients. A randomized, comparative study is justified to further evaluate PreveLeak and confirm the findings from this study., (© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: Postoperative atrial fibrillation (POAF) is a common complication arising after coronary artery bypass grafting (CABG) and valve replacement or repair surgeries. POAF has been associated with increased mortality, morbidity and cost., Methods: The study was conducted to evaluate the incidence of POAF following CABG, valve or combination surgeries when perioperative ranolazine (1,000 mg preoperatively, then 1,000 mg twice daily for 7 days or until discharge) was or was not added to standard therapy., Results: A total of 205 patients were evaluated for POAF after CABG, valve or combination surgeries. POAF occurred less frequently in the ranolazine group compared with the non-ranolazine group in unmatched analysis (10.1 vs. 41.9 %, p < 0.0001). After adjusting for potential sources of bias through propensity-score matched-pair analysis and conditional logistic regression, ranolazine was an independent predictor of preventing POAF (p < 0.0001). There were no differences in bradycardia, new renal failure or neurological events between the two groups. Early, symptomatic hypotension occurred more frequently in the ranolazine group (p = 0.0004) although this difference did not persist after 72 h. No significant difference was found in the length of stay in the intensive care unit following cardiac surgery. While a significant difference was found in the hospital readmission rate for a cardiac cause within 30 days in the unmatched analysis (p = 0.046), this difference was nonexistent after matching (p = 0.39). No difference was found in 30-day cardiovascular mortality., Conclusion: Adding ranolazine to standard therapy was independently associated with a significant decrease in POAF development after CABG, valve or combination surgeries.

Objectives: Patients undergoing coronary bypass grafting (CABG) are at higher risk if they suffer from atrial fibrillation (AF). It was suggested that performing CABG without the use of cardiopulmonary bypass (off-pump) would reduce perioperative risk. We assessed the influence of preoperative AF on outcome in a randomized cohort of patients above the age of 75 undergoing either on-pump or off-pump CABG., Methods: The German Off-Pump Coronary Artery Bypass grafting in the Elderly trial, a randomized, controlled multicentre trial conducted at 12 German institutions, enrolled 2303 patients between 2008 and 2011. The presence of AF was recorded at admission and discharge. There was no record on the rhythm status during hospital stay., Results: AF at admission was present in 5% in the on-pump (121/1158) and 5% in the off-pump (112/1145) group. The number of patients with AF at discharge was not different between these two groups (10% on pump, 10% off pump). As expected, AF patients had worse preoperative conditions, which had a negative impact on outcome: The combined end-point of death, infarction, stroke, dialysis and revascularization occurred more often (13 vs 8%, P = 0.008) and 30-day mortality was significantly higher (6 vs 2%, P = 0.003) in AF patients. However, the operative technique used for CABG did not affect these outcome parameters., Conclusions: AF at admission is a significant risk factor for elderly patients undergoing coronary bypass grafting. However, this risk is not altered by performing bypass grafting off pump., (© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: Cardiogenic shock (CS) complicating acute myocardial infarction (AMI) is associated with high mortality. Previous studies regarding gender-specific differences in CS are conflicting and there are insufficient data for the presence of gender-associated differences in the contemporary percutaneous coronary intervention era. Aim of this study was therefore to investigate gender-specific differences in a large cohort of AMI patients with CS undergoing contemporary treatment., Methods: In the randomized Intra-aortic Balloon Pump in Cardiogenic Shock II (IABP-SHOCK II) trial, 600 patients with CS complicating AMI undergoing early revascularization were assigned to therapy with or without intra-aortic balloon pump. We compared sex-specific differences in these patients with regard to baseline and procedural characteristics as well as short- and long-term clinical outcome., Results: Of 600 patients 187 (31%) were female. Women were significantly older than men and had a significantly lower systolic and diastolic blood pressure at presentation (p < 0.05 for all). Diabetes mellitus and hypertension were more frequent in women, whereas smoking was more frequent in men (p < 0.05 for all). Women showed a higher mortality within the first day after randomization (p = 0.004). However, after multivariable adjustment this numerical difference was no longer statistically significant. No gender-related differences in clinical outcome were observed after 1, 6 and 12 months of follow-up., Conclusion: In this large-scale multicenter study in patients with CS complicating AMI, women had a worse-risk profile in comparison to men. No significant gender-related differences in treatment as well as short- and long-term outcome were observed.

Background: An exploratory analysis of the German Off Pump Coronary Artery Bypass Grafting in Elderly Patients (GOPCABE) trial was performed to investigate the effect of off-pump coronary artery bypass grafting (CABG) on kidney function after the operation., Methods: Data on kidney function were available from 1,612 patients, representing 67% of the study population. Preoperative kidney function was graded according to the glomerular filtration rate. Acute kidney injury (AKI) within the first week after the operation was defined and classified according to the Acute Kidney Injury Network (AKIN) criteria. The incidence and severity of AKI was compared between patients operated on on-pump or off-pump., Results: Impaired kidney function was seen in 642 patients (40%), and 19 patients had preexisting end-stage kidney disease. AKI of any severity occurred in half of all patients undergoing CABG, with AKIN stage 1 accounting for most of the cases. The incidence and severity of AKI in patients undergoing on-pump vs off-pump CABG was AKIN stage 1: 298 (37%) vs 329 (42%); AKIN stage 2: 38 (5%) vs 43 (5%); and AKIN stage 3: 44 (6%) vs 44 (6%), which did not differ significantly (p=0.174). New renal replacement therapy was necessary in 3.2% (on-pump) and in 2.7% (off-pump) of all patients. Stratification according to preoperative kidney function yielded comparable frequencies of AKI for on-pump and off-pump CABG., Conclusions: AKI was common in elderly patients undergoing CABG, but deterioration of kidney function requiring renal replacement therapy was a rare event. Off-pump CABG was not associated with decreased rates or reduced severity of AKI in elderly patients., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Myoglobin has become established as a serum marker of myocardial injury. However, myoglobin levels can increase exponentially without any correlation to postoperative clinical ischemia symptoms. In this retrospective study, we analyzed the associated factors for a non-ischemic myoglobin release., Methods: We performed a data analysis from 532 consecutive cardiac surgery patients (2010 to 2011, 73% males; age 65 ± 11 years). Non-ischemic myoglobin elevation was defined as CK-MB <50 U/l and/or the absence of any ischemic clinical events (eg, myocardial infarction, mesenteric vascular occlusion)., Results: Using a multifactorial model, predictive elements and associated factors for non-ischemic myoglobin increase were male sex, ejection fraction < 30%, BMI > 30 and transfusions. Serum myoglobin was not significantly different in patients with high muscle mass., Conclusions: A non-ischemic serum myoglobin release is rare, but could be associated in subgroups of patients. Further investigations should focus on clinical targets, for example, concomitant medications for which our study was not powered.

Background: A specific risk model concerning mortality of patients undergoing isolated coronary artery bypass grafting (CABG) is developed based on the national quality benchmarking mandatory by law in Germany., Methods: On the basis of the national data pool from 2004, a risk score model for patients undergoing isolated CABG was developed and finally adjusted with the data of 43,145 patients of the year 2008. Modeling was performed by logistic regression analysis. This risk model was validated with the 2007 data pool which comprised 45,569 patients., Results: Observed in-hospital mortality after isolated CABG procedures was 3.0% in 2008. Hosmer-Lemeshow test p value was 0.189 and area under receiver operating characteristic curve was 0.826. Applying the German CABG score for 2007 resulted in an observed-to-expected mortality ratio of 1.01., Conclusion: The German CABG score for in-hospital mortality is a risk score with proven validity for isolated CABG, developed by means of the patient population in Germany. It can be used for the assessment of patient risk groups and for interhospital benchmarking. We encourage other researchers to apply and validate this score in comparable health care systems., (Georg Thieme Verlag KG Stuttgart · New York.)

Objectives: Patients undergoing cardiac surgery presenting with chronic obstructive pulmonary disease (COPD) have a higher 30-day mortality risk. In these patients, pulmonary dysfunction linked to an inflammatory response is frequent after cardiac operations using cardiopulmonary bypass (CPB), which causes pulmonary hypoperfusion. We hypothesize that selective pulmonary perfusion (sPP) of the lungs leads to a reduction of pulmonary inflammation and a better clinical outcome., Methods: Fifty-nine COPD patients (forced expiratory volume in 1 s/vital capacity <70%) undergoing cardiac surgery procedures (coronary artery bypass grafting 64%, valve 14%) were block-randomized to sPP (venous blood, temperature 2°C, 4 l) or standard CPB (28/28). The primary end-point of the study was to evaluate the effect of pulmonary perfusion on gas exchange by measuring alveolar-arterial oxygen gradient. The surrogate end-points were inflammatory response, intensive care unit (ICU) stay, time on respirator (TOR) and major adverse cardiac and cerebrovascular events. A cytokine assay for interleukin-1β, IL-6, IL-10, tumour necrosis factor-α (TNF-α) and polymorphonuclear elastase was performed with peripheral blood at different time-points [(t1) pre-CPB, (t2) end of CPB, (t3) 3 h, (t4) 24 h, (t5) 48 h postoperatively]. Repeated-measure analysis of variance and non-parametric statistics were used to assess the between-group and during time differences., Results: The two groups proved comparable for perioperative variables. Serum cytokines were not different in the two groups throughout the study (P > 0.05 at single time-points), but as a function of time, the markers of the inflammatory response increased after CBP (P < 0.05 pre-CPB to 24 h). Clinical end-points were statistically comparable in both groups, but with a trend towards a shorter TOR (72 ± 159 h/106 ± 193 h) and ICU stay (3.9 ± 7.2 days/5.5 ± 9.2 days) in the sPP group despite a slightly longer time on extracorporeal circulation (120 vs 158 min)., Conclusions: These results indicate a non-significant trend that repeated hypothermic lung perfusion with venous blood during CPB may have a protective effect on the lungs. A multicentre study design and larger cohort seem necessary to demonstrate the benefits of sPP more clearly., (© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: The aims of this study are (1) to investigate the occurrence rate of postoperative complications in patients ≥ 80 years old after cardiac surgery and (2) to elucidate the impact of the most common postoperative complications on mortality., Methods: Between January 1998 and December 2007, 649 patients aged over 80 years received isolated first-time coronary artery bypass graft (CABG), isolated aortic valve replacement (AVR) or a combination of both in our institute. Prospectively entered patient data were analyzed with respect to major complications and outcome parameters., Results: Acute renal failure (55.0% vs. 7.5%, p = 0.0001), low cardiac out-put syndrome (43.1% vs. 8.8%, p = 0.0001), sepsis (52.0% vs. 10.3%, p = 0.0001), prolonged respiratory failure with tracheotomy (29.0% vs. 11.0%, p = 0.002), re-thoracotomy due to bleeding (26.9% vs. 10.6%, p = 0.0001), and postoperative laparotomy (30.8% vs. 11.5%, p = 0.033) had a significant impact on mortality. A multivariate analysis revealed that advanced age (OR 1.130, 95%CI; 1.017-1.256, p = 0.023), low output syndrome (OR 5.094, 95%CI; 1.1635-15.871, p = 0.005), renal failure (OR 8.128, 95%CI; 3.347-19.742, p = 0.0001) and sepsis (OR 4.975, 95%CI; 1.420-17.426, p = 0.012) as independent risk factors., Conclusions: The present study demonstrates that among major complications, low output syndrome, renal failure requiring renal replacement therapy and sepsis, dramatically impaired the postoperative course patients aged over 80 years undergoing CABG, AVR or combined CABG and AVR.

Background: The aim of this study was to evaluate the long-term outcome (4 years) of high-intensity-focused-ultrasound (HIFU) cardiac ablation, the significance of postablation antiarrhythmic drugs (AADs) and predictors of successful sinus rhythm (SR) restoration., Methods: 103 patients were prospectively enrolled in a single-center study. The preoperative atrial fibrillation (AF) type was paroxysmal in 36%, permanent in 53%, persistent in 5% and flutter in 6% patients. The left atrial diameter was <50 mm in 78 patients and >50 mm in 25. Long-term results, up to 4 years, and postablation antiarrhythmics were evaluated. Follow-up studies including 12-lead electrocardiogram (ECG) and 24-h Holter ECG obtained at 3 and 6 months in our institute, and 12, 24, and 48 months during outpatient visits., Results: No device- or procedure-related complications or deaths were observed. A pacemaker was implanted in 5% patients. Freedom from AF and flutter at 6-/12-/and 48-month visit were 66%/63%/68% for the entire population, 84%/77%/90% in patients with paroxysmal AF, 50%/46%/40% in patients with permanent AF and at any time in all 6 patients with flutter. No significant changes were noted at 2 years.Postablation results were not statistically different in patients on or not on antiarrhythmic therapy. At discharge, 53% of patients on antiarrhythmics and 55%, not on AADs were free of AF. At the 6-month visit, 66% of patients on AADs versus 69% of patients, not on AADs presented with SR, an improved outcome by 13 percentage points with AADs versus 14 percentage points without AADs (p = 0.65). Patients taking a β-blocker showed better results in restoration/maintenance of SR after 6 months. No significant difference was noted regarding the use of UltraWand.Sixty-seven percent with a left atrium (LA) diameter <50 mm were successfully converted into SR, vs. 48% with an LA diameter >50 mm. Best results were achieved in patients with paroxysmal AF and LA <50 mm with 81% freedom of AF., Conclusion: AF treatment with HIFU ablation during concomitant cardiac surgery is a safe and effective procedure for restoring SR, especially in patients with AF and especially in patients with a smaller left atrial diameter. No significant difference was noted between the antiarrhythmic and non drug groups regarding restoration and maintaining SR; however, better results were achieved by those taking a β-blocker.

Background: The impact of minimized extracorporeal circulation (MECC) for emergency revascularization remains controversial., Methods: A total of 348 patients underwent emergency CABG with MECC (n=146) or conventional extracorporeal circulation (CECC; n=175) between January 2005 and December 2010. Using propensity score matching after binary logistic regression, 100 patients, who underwent CABG with MECC could be matched with 100 patients, who underwent CABG with CECC. Primary outcome was 30-day mortality., Results: Unadjusted 30-day mortality was 14.8% in patients with CECC and 6.9% in those with MECC (mean difference -7.9%; p=0.03). The adjusted mean difference (average treatment effect of the treated, ATT) after matching was -1.0% (95% CI -8.6 to 7.6; p=1.0). Intensive care unit stay (adjusted mean difference 1.0; 95% CI -0.2 to 3.2; p=0.70) and hospital stay (adjusted mean difference 1.0; 95% CI -2.0 to 3.6; p=0.40) did not show significant differences between both groups. The adjusted mean difference for postoperative low cardiac output syndrome was -1.1% (95% CI -7.3 to 7.1; p=0.83) without significant differences between CECC and MECC. Postoperative mechanical ventilation time, drain loss, postoperative rethoracotomy, postoperative neurological events, new onset renal replacement therapy and respiratory failure also had insignificant average treatment effects of the treated. In addition, all average treatment effects (ATEs) did not significantly differ between both groups., Conclusion: Using propensity score estimation and matching, we did not observe significant differences in terms of survival and further outcomes in patients who undergo emergency CABG with CECC or MECC, but our results call for further analysis.

Objectives: The aim of this prospective, randomized trial was to assess the 10-year long-term safety and effectiveness of percutaneous coronary intervention (PCI) and minimally invasive direct coronary artery bypass surgery (MIDCAB) for the treatment of proximal left anterior descending (LAD) lesions., Background: Long-term follow-up data comparing PCI and MIDCAB surgery for isolated proximal LAD lesions are sparse., Methods: Patients with significant isolated proximal LAD stenoses were randomized either to PCI with bare-metal stents (n = 110) or MIDCAB (n = 110). At 10 years, data were obtained with respect to the primary endpoint (death, myocardial infarction, target vessel revascularization). Angina was assessed by the Canadian Cardiovascular Society classification., Results: Follow-up was conducted for 212 patients at a median time of 10.3 years. There were no significant differences in the binary primary composite endpoint (47% vs. 36%; p = 0.12) and hard endpoints (death and infarction) between PCI and MIDCAB. However, a higher target vessel revascularization rate in the PCI group (34% vs. 11%; p < 0.01) was observed. Clinical symptoms improved significantly from baseline and were similar between both treatment groups., Conclusions: At 10-year follow-up, PCI and MIDCAB in isolated proximal LAD lesions yielded similar long-term outcomes regarding the primary composite clinical endpoint. Target vessel revascularization was more frequent in the PCI group., (Copyright © 2013 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: This study evaluates the impact of gender in dialysis-dependent patients undergoing cardiac surgery., Methods: We retrospectively identified 204 dialysis-dependent patients (68.6% male, aged 66.6 ± 9.9 years) with end-stage renal disease undergoing cardiac surgery and compared them to a propensity-score-pair-matched control collective., Results: A 30-day mortality was 13.2% (14/106) for coronary artery bypass grafting (CABG), 19.3% (6/31) for aortic valve replacement (AVR), and 23.8% (16/67) for combined procedures. Postoperative chest tube output was significantly higher in men (1,007 ± 946 mL) versus women (687 ± 598 mL, p = 0.014). Compared with a propensity-score-pair-matched control collective of 204 patients, we identified significant differences in terms of 30-day mortality: overall mortality revealed 17.6 versus 4.6% (p = 0.0001), 13.2 versus 3.4% (p = 0.014) for CABG, 19.3 versus 0% (p = 0.051) for AVR, and 23.8 versus 9.1% (p = 0.02) for combined procedures., Conclusion: Multivariate analysis identified preoperative myocardial infarction, prolonged extracorporeal circulation time, operation time, and surgical reexploration as independent predictors of 30-day mortality. There was a higher occurrence of bleeding complications in men that remained significant even after correction for body surface area., (Georg Thieme Verlag KG Stuttgart · New York.)

Objectives: Minimal extracorporeal circulation (MECC) has been introduced in coronary artery bypass graft (CABG) surgery, offering clinical benefits owing to reduced hemodilution and no blood-air interface. Yet, the effects of MECC on the intraoperative microvascular perfusion in comparison with conventional extracorporeal circulation (CECC) have not been studied so far., Methods: The current study aimed to analyze alterations in microvascular perfusion at 4 predefined time points (T1-T4) during on-pump CABG using orthogonal polarization spectral imaging. Forty patients were randomized for being operated on with either MECC or CECC. Changes in functional capillary density (FCD), blood flow velocity, and vessel diameter were analyzed by a blinded investigator., Results: After start of extracorporeal circulation (ECC) and aortic crossclamping (T2), both groups showed a significant drop of FCD, with a significantly higher FCD in the MECC group (206.8 ± 33.6 cm/cm² in CECC group versus 217.8 ± 35.3 cm/cm² in MECC group; P = .034). In the late phase of the ECC (T3), FCD in the MECC group was already recovered, whereas FCD in the CECC group was still significantly depressed (223.1 ± 35.6 cm/cm² in MECC group; P = .100 vs T1; 211.1 ± 36.9 cm/cm² in CECC group; P = .017 vs T1). After termination of ECC (T4), FCD recovered in both groups to baseline. Blood flow velocity tended to be higher in the MECC group, with a significant intergroup difference after aortic crossclamping (T2)., Conclusions: Orthogonal polarization spectral imaging data reveal an impairment of microvascular perfusion during on-pump CABG. Changes in FCD indicate a faster recovery of the microvascular perfusion in MECC during the reperfusion period. Beneficial recovery of microvascular organ perfusion could partly explain the perioperative advantages reported for MECC., (Copyright © 2012 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Object: The predominant mechanism of early graft failure after coronary artery bypass grafting (CABG) is associated with antiplatelet treatment using drugs such as acetylsalicylic acid (ASA). Impaired hemostasis of multiple etiologies is often present in patients undergoing on-pump cardiac surgery. We investigated the impact of intravenous ASA administration on platelet function in this setting., Methods: Forty-two patients were enrolled in the study. Patients received 100 mg oral ASA once daily, beginning in the early postoperative period. Noncompliance was eliminated by the administration of 300 mg ASA intravenously at 6-8 days post-operation. Blood was drawn immediately before, 1 h and 24 h after ASA administration., Results: A platelet function analyzer (PFA-100™) was used to evaluate closure time (CT), turbidimetric platelet aggregation (TPA) and impedance platelet aggregation (IPA) induced by arachidonic acid (AA), collagen and ADP and results were compared with the respective values from 120 healthy individuals. At 1 h and 24 h after administration, we found that intravenous ASA caused CEPI-CT to be significantly prolonged with a reduction of AA and collagen-induced IPA. Despite postoperative oral ASA administration for 6-8 days, PFA-100™ CEPI and CADP-CT were significantly shorter and ADP-TPA and IPA values induced by any agonist were significantly greater in patients than in controls. Intravenous ASA had no significant influence on CADP-CT or ADP-induced IPA (ADP-IPA)., Conclusion: Platelet tests for diagnosing patients as aspirin responders (ASA-R) or aspirin non-responders (ASA-NR) were found to be not comparable. Patients after CABG show augmented platelet dysfunction. Intravenous ASA administration may indicate a promising approach to reduce laboratory resistance after CABG procedure. The reason for this is not clear and requires additional clinical studies., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: The accuracy of the logistic EuroSCORE in different patient populations has been questioned. Using the German registry database, the KoronarCHirurgie (KCH) score was introduced as a preoperative risk stratification tool specifically for patients who undergo isolated coronary artery bypass surgery in Germany. However, no direct statistical comparison of this score with the well-established logistic EuroSCORE has been previously performed. The aim of this study was to validate the preoperative German KCH score and to compare it to the logistic EuroSCORE for all coronary artery bypass surgery patients as well as for on-pump and off-pump subgroups., Methods: We prospectively included all consecutive adult patients admitted to our department between January 1, 2007 and December 31, 2008, who underwent isolated coronary artery bypass surgery. The logistic EuroSCORE and the KCH-3.0 were calculated on admission to hospital. The outcome was defined as 30-day mortality. We performed calibration (Hosmer-Lemeshow test and Anderson-Grunkemeier Observed/Expected "O/E" mortality ratio) and discrimination (receiver operating characteristic "ROC" test) analyses of both scores. The accuracy of the scores was compared using DeLong's test., Results: A total of 1461 patients (23.96 % females, mean age 66.94 ± 9.43 years) were included. The 30-day mortality rate was 2.87 %. The two models were comparable with regard to the prediction of an individual patient's risk of mortality in the whole study population and in the on-pump and off-pump subgroups (according to the ROC test and DeLong's test). Overall, there was no significant difference between observed and expected mortality according to the Hosmer-Lemeshow test ( P > 0.05). However, the KCH-3.0 was far less likely to overpredict mortality than the logistic EuroSCORE, as demonstrated by the observed mortality/expected mortality (O/E) ratios. The O/E ratio was 0.32 for the logistic EuroSCORE and 0.74 for the KCH-3.0. For the on-pump subgroup the O/E ratios were 0.37 and 0.80, respectively, and 0.24 and 0.63, respectively, for the off-pump subgroup., Conclusions: The KCH-3.0 is more reliable than the logistic EuroSCORE as a preoperative mortality prediction score for patients undergoing isolated coronary artery bypass surgery, providing predicted mortality rates that are closer to the actual mortality rates with a lower overprediction of mortality., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Intra-aortic balloon pump (IABP) is an established therapy to support patients with heart failure during coronary artery bypass grafting (CABG). The impact of the timing of IABP on the hospital course and on follow-up is of particular clinical interest. The purpose of this study was to analyze the relationship between the time of IABP implantation and its impact on early, mid- and long-term survival in patients with acute myocardial infarction (AMI) who underwent emergent CABG for NSTEMI and STEMI., Methods: A total of 472 patients with AMI (NSTEMI and STEMI) underwent emergency CABG at our institution; 158 of them additionally received IABP support. Fifty-seven (36 %) patients received preoperative and 101 (64 %) patients underwent intraoperative IABP implantation. Endpoints were in-hospital und follow-up (mean duration 37 ± 28 months) survival., Results: Overall in-hospital mortality was 17.1 % (n = 27): 17.6 % (n = 10) in the preoperative group and 16.8 % (n = 17) in the intraoperative group ( P = ns). Mid- and long-term survival rates were comparable for both groups 78.6 % vs. 73.7 %, 71.4 % vs. 68.7 % and 64.3 % vs. 54.6 % at 1, 3 and 5 years, respectively ( P = ns)., Conclusion: This study demonstrates that CABG with IABP support in high-risk patients with AMI can be performed with acceptable in-hospital and long-term survival rates. The decision for IABP placement should consider the preoperative clinical condition and the intraoperative course of each patient. IABP placement does not appear to affect the long-term outcome after isolated CABG in patients with AMI., (© Georg Thieme Verlag KG Stuttgart · New York.)

Objective: This analysis was undertaken to evaluate the results of persistent atrial fibrillation (pAF) ablation procedures concomitant to coronary surgery and to identify the risk factors for pAF recurrence., Methods: Since 2001, a total of 126 consecutive patients with pAF (duration: 0.5-33 years) underwent ablation concomitant to coronary surgery (isolated or in combination with valve surgery), whereby two encircling isolation lesions around the left and the right pulmonary veins and a connecting lesion between both was created using radiofrequency ablation. Patients were reevaluated at discharge, 3 months and 3 years after surgery., Results: Survivals at the time of reexamination were 96.8, 95.1 and 94.7 %, respectively. Stable sinus rhythm (SR) could be documented in 66.4, 75.1 and 75.9 % of surviving patients. Long-term pAF before surgery and a larger left atrium (LA) were predictive of postoperative pAF return ( P < 0.01). Statistical analysis demonstrated a cut-off point of 5 years for pAF and 50 mm for LA diameter: 89.1 % of patients with pAF duration of < 5 years and 86.2 % of patients with LA size of ≤ 50 mm were in stable SR at late follow-up. Cardiac rhythm at 3 months was predictive for long-term rhythm prognosis ( P < 0.01). Age, gender and concomitant diseases (e.g. arterial hypertension, diabetes, renal insufficiency), and the underlying cause of heart disease did not significantly influence the postoperative cardiac rhythm., Conclusions: The duration of pAF and the LA size are the most reliable preoperative variables to predict the success rate of ablation in patients undergoing coronary surgery. The probability of re-establishing stable SR is excellent when pAF duration is short and LA size is small., (© Georg Thieme Verlag KG Stuttgart · New York.)

Aim: The combination of the two cardiac support mechanisms of intra-aortic balloon pumping (IABP) and non-pulsatile circulatory extracorporeal membrane oxygenation (ECMO) has been confirmed to improve efficacy of the cardiac support as a whole. However, reports on benefits of diastolic augmentation on coronary vascular bed and graft flowmetry during concomitant use of IABP and ECMO are lacking. The aim of this study was to evaluate the acute impact of IABP support on coronary vascular resistance (CVR) and coronary bypass flows (CBF) in high-risk patients with peripheral ECMO following coronary artery bypass grafting (CABG)., Methods: In eight emergency CABG patients (mean age=67.8±1.9 years; gender: six male and two female; EF=25.5±2.4%) requiring mechanical circulatory support with ECMO hemodynamic parameters, CVR, CBF, diastolic filling index (DFI), graft flow reserve (GFR), and pulsatility index (PI) were analyzed with and without diastolic augmentation using a transit time flowmeter., Results: The addition of IABP to ECMO decreased CVR significantly by 6.5%±1.9% compared to baseline with ECMO alone (1.62±0.2 versus 1.78±0.2; P<0.0045). Accordingly, significant higher mean CBF were found during IABP assist, resulting in a 21.6%±2.6% increase (60.7±8.7 mL/min with versus 51.3±7.4 mL/min without IABP; P<0.0001). IABP also significantly increased DFI by 9.8±0.9% (73.2%±1.4% with versus 66.7%±1.3% without IABP; P<0.0001). GFR was recruited during IABP in all grafts (GFR>1). There were no statistically significant differences in PI with and without IABP assistance (2.6±0.1 versus 2.5±0.2)., Conclusion: IABP-induced pulsatility significantly improves diastolic filling index and mean coronary bypass graft flows by lowering coronary vascular resistance during non-pulsatile peripheral ECMO. The combination of ECMO with IABP may provide more optimal myocardial oxygen conditions resulting in an improved efficacy of the cardiac support as a whole in critical ill patients with postcardiotomy myocardial dysfunction following CABG.

In a number of studies, centrifugal blood pumps--in comparison with roller pumps--have been shown to attenuate trauma to blood components. Nevertheless, the impact of these results on the postoperative course needs to be discussed controversially. In a prospective randomized study, 240 consecutive adult patients underwent elective myocardial revascularization with cardiopulmonary bypass employing five different pumps (Roller, Avecor, Sarns, Rotaflow, Bio-Medicus). We analyzed clinical course, blood loss, damage of blood components, and impairment of the hemostatic system. The study population was homogenous with respect to age, gender, myocardial function, and operative data. No differences were found with respect to time of ventilation, duration of intensive care stay, hospitalization, and laboratory data. The choice of arterial pump during standard extracorporeal bypass for elective coronary artery bypass grafting is no matter of concern., (© 2011, Copyright the Authors. Artificial Organs © 2011, International Center for Artificial Organs and Transplantation and Wiley Periodicals, Inc.)

Objectives: To evaluate feasibility and safety of MGuard based percutaneous coronary interventions (PCI) in vein grafts (VG) and native coronaries (NC)., Background: Distal embolization is a frequent complication of PCI of VG and NC during acute coronary syndromes (ACS). MGuard was a stent designed to reduce embolization., Methods: Prospective, single arm, two-center trial assessing the feasibility and safety of MGuard-based PCI with post-PCI clinical and laboratory monitoring including: cardiac biomarkers, ECG and 6-month angiography., Results: Forty-one patients with mean age of 68.2±10.1 years were enrolled. Mean VG age (n=23) was 14.4±4.3 years. All patients received heparin, clopidogrel and aspirin; while none received glycoprotein IIb/IIIa inhibitors, or embolic protection device (EPD). Device and procedural success were 100% and 95.1% respectively. Two patients (4.9%) experienced procedure-related creatinine phosphokinase rise. At 6 months one patient had myocardial infarction and 19.5% had target vessel revascularization (TLR). Late follow up (12-27 months) revealed one additional TLR., Conclusion: MGuard based PCI of NC and VG appears encouraging especially in view of unfavorable patient and lesion characteristics. Efficacy needs to be further established in larger randomized trials., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Introduction: The aim of this study was to prospectively assess the clinical outcome and quality of life of elderly patients who underwent either coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) with drug-eluting stents (DES) for treatment of significant left main disease (LMD) compared to a younger patient population., Methods: Consecutive patients, admitted into our institution between 04/2004 and 12/2007 with LMD and a life expectancy of >1 year were prospectively included and stratified in two groups (either CABG or left main stenting [LMS] with DES) based on the patients' age at inclusion (> or ≤75 years). Rates of death, myocardial infarction (MI), stroke, and target lesion revascularization (TLR) were evaluated over a 12 month follow-up. Six months after the initial procedure, additionally, quality of life was assessed using the SF-36 questionnaire., Results: A total of 300 patients was included; 56 of the 95 PCI patients (59%) were ≤75 years and 39 (44%) >75 years, whereas 155 of 205 patients in the CABG group were ≤75 years (76%), and 50 patients (24%) were >75 years. Mean follow-up was 312 ± 226 days in the PCI and 377 ± 286 in the CABG group. Rates of death and MI were not significantly different between the four groups at the end of follow-up. There was no difference in quality of life after 6 months., Conclusion: In this prospective trial, PCI of LM with DES in elderly patients was feasible with a short- and intermediate term outcome comparable to CABG procedure and to a younger patient cohort.

Background: We evaluated the process of changing from conventional coronary artery bypass grafting (CABG) to totally arterial off-pump coronary artery bypass (TOPCAB) at a single heart center in Germany., Methods: We (1) used multivariate statistical methods to assess real-time monitoring of OPCAB effects, (2) conducted a case review to assess preventable deaths and identify areas of improvement, (3) conducted a team survey, and (4) evaluated benchmarking results., Results: All surgeons and assistants (n = 18) at this center were involved and were guided by the department head and one of the consultants, who was trained in this procedure in 2004 at the Leuven OPCAB school. The frequency of OPCAB operations increased abruptly in 2005 from 5% to 43% and then increased gradually to 67% (n = 546) by 2008 (total, 1781 OPCAB cases and 1563 on-pump cases). The in-hospital and 30-day mortality rates for OPCAB surgeries (n = 10 [0.6%] and 21 [1.2%], respectively) were lower than for on-pump surgeries (n = 27 [1.7%] and 26 [1.7%], respectively). Stroke rates were also lower for OPCAB surgeries (7 cases [0.4%] versus 15 cases [1%]). The lower risk of stroke in the OPCAB group was significant (P < .05) after risk adjustment. Monitoring curves and case reviews demonstrated a preventable death percentage of at least 30%. The attitude of the team was mostly positive because of the promising results (eg, fewer strokes, increasing TOPCAB popularity, and a top national rank)., Conclusions: The change from conventional CABG to TOPCAB was effective in decreasing the incidence and severity of stroke, in developing a team routine and a positive team attitude, and in producing excellent benchmarking results. The presence of a training and communication deficiency at the beginning of the study suggested an area for further improvement. After 6 years TOPCAB had largely replaced conventional CABG.

Background: Chronic heart failure after myocardial infarction is still a serious problem without a fundamental therapy. Experimental transplantation of bone marrow cells (BMC) into infarcted myocardium resulted in regeneration and functional improvement., Objective: Clinical investigation of safety and efficacy of intracardiac transplantation of unselected autologous BMC., Method: 22 patients scheduled for elective and isolated coronary artery bypass grafting (CABG) with a reduced LVEF due to myocardial infarction were included. Intraoperatively, sternal bone marrow blood was aspirated, and a sterile buffy coat was prepared and applicated. 19 age, LVEF and coronary disease matched patients served as controls. Heart function, geometry, and scar proportion were assessed by echocardiography and Gadolinium-MRI at the time of the operation and 6 months thereafter., Results: Transplanted patients received a mean number of 360 × 10⁶ BMC. We did not notice any significant differences in early or late complications in the transplant group as compared to controls. At six months follow up only the transplanted patients showed a significant improvement of NYHA classes from 2.7 to 1.5 and of LVEF from 36 to 43 %, (p < 0.05). Furthermore, only CABG concomitant with BMC-TX led to a significant reduction of left ventricular end diastolic diameter (LVEDD) from 59 to 54 mm and of scar proportion of the infarcted segments from 2.53 to 2.42, (p < 0.05)., Conclusion: Intracardiac transplantation of unselected, autologous BMC is safe and feasible. In adjunct with coronary revascularization it leads to an improvement of ventricular geometry and function. Moreover, it reduces myocardial scar proportion and heart failure symptoms.

Background: Due to an increasing number of comorbidities there is still a significant incidence of respiratory failure after primary postoperative extubation in patients who undergo cardiosurgery. We wanted to study whether nCPAP could improve pulmonary oxygen transfer and avoid the necessity for reintubation after cardiac surgery. Additionally, we compared this protocol to noninvasive positive pressure ventilation (NPPV)., Patients and Methods: Over a period of 3 years we analyzed all patients who were extubated within 12 hours after cardiac surgery, and in whom pulmonary oxygen transfer (PaO₂/FIO₂) deteriorated without hypercapnia so that all these patients met predefined criteria for reintubation. There were three groups of patients: A = patients required immediate reintubation (n = 125); B = patients had nCPAP with intermittent mask CPAP (n = 264); and C = patients had NPPV (n = 36)., Results: 25.8 % of patients in Group B and 22.2 % of patients in Group C were also intubated after a period of CPAP or NPPV. All other patients of Groups B and C could be weaned from these devices (B: 33.4 ± 5.8 hours, C: 26.2 ± 4.2 h; P < 0.05) and were well oxygenated using a face mask at ambient pressures (PaO₂/FIO₂: B: 136 ± 12, C: 141 ± 12). In Group A, we found a higher mortality (8.8 %) than in Group B (4.2 %) and Group C (5.6 %). The ICU stay and in-hospital stay were significantly prolonged in Group A. The incidence of pulmonary infections (A: 24 %, B: 10.6 %, C: 13.8 %; P < 0.05) and the need for catecholamines were significantly increased in Group A, whereas nCPAP patients suffered significantly more often from impaired sternal wound healing (A: 4.8 %, B: 8.3 %; P < 0.05)., Conclusions: We conclude that reintubation after cardiac operations should be avoided since nCPAP and NPPV are safe and effectively improve arterial oxygenation in the majority of patients with nonhypercapnic oxygenation failure. However, it is of great importance to pay special care to sternal wound complications in these patients., (© Georg Thieme Verlag KG Stuttgart · New York.)

Objectives: We sought to assess the accuracy of an integrated cardiac magnetic resonance (CMR) protocol for the diagnosis of relevant coronary artery or bypass graft stenosis in patients with suspected coronary artery disease (CAD) or with previously performed percutaneous coronary intervention (PCI) or coronary bypass graft surgery (CABG)., Background: CMR is suitable for diagnosing inducible myocardial ischemia in patients with suspected CAD and has been proven to be a helpful diagnostic tool for decision of further treatment. However, little is known about its diagnostic accuracy in patients with known CAD who previously were treated by PCI or CABG., Methods: A total of 477 patients with suspected CAD, 236 with previous PCI, and 110 after CABG referred for coronary X-ray angiography (CXA) underwent an integrated CMR examination before CXA. Myocardial ischemia was assessed using first-pass perfusion after vasodilator stress with adenosine (140 microg/kg/min for 3 min) using gadolinium-based contrast agents (0.1 mmol/kg). Late gadolinium enhancement (LGE) was assessed 10 min after a second contrast bolus., Results: CXA demonstrated a relevant coronary vessel stenosis (> or =70% luminal reduction) in 313 (38%) patients using quantitative coronary analysis. The combination of CMR perfusion and LGE assessment for detecting a relevant coronary stenosis in patients with suspected CAD yielded sensitivity and specificity of 0.94 and 0.87, in PCI patients 0.91 and 0.90, and in CABG patients 0.79 and 0.77, respectively., Conclusions: A combined CMR protocol for the assessment of myocardial perfusion and LGE is feasible for the detection of relevant coronary vessel stenosis even in patients who previously were treated by PCI or CAG in a routine clinical setting. However, diagnostic accuracy is reduced in patients with CABG. This could be due to different flow and perfusion kinetic. Further studies are needed to optimize the clinical protocols especially in post-surgical patients.

Objectives: Do prior percutaneous coronary interventions adversely affect the outcome of subsequent coronary artery bypass grafting? We investigated this effect on a multicenter basis., Methods: Eight cardiac surgical centers provided outcome data of 37,140 consecutive patients who underwent isolated first-time coronary bypass grafting between January 2000 and December 2005. Twenty-two patient characteristics and outcome variables were retrieved. Three groups of patients were analysed for in-hospital mortality and in-hospital major adverse cardiac events: patients without a previous percutaneous coronary intervention, with 1 previous intervention, and with 2 or more previous percutaneous coronary interventions before bypass grafting. A total of 29,928 patients with complete information for prior percutaneous coronary intervention underwent final analysis. Unadjusted univariate and risk-adjusted multivariate logistic regression analysis as well as computed propensity score matching were performed, based on 14 major risk factors to correct for and minimize selection bias., Results: A total of 10.3% of patients had 1 previous percutaneous coronary intervention, and 3.7% of patients had 2 or more previous interventions. Risk-adjusted multivariate logistic regression analysis revealed a significant association of 2 or more previous percutaneous coronary interventions with in-hospital mortality (odds ratio [OR], 2.0; confidence interval [CI], 1.4-3.0; P = .0005) and major adverse cardiac events (OR, 1.5; CI, 1.2-1.9; P = .0013). After propensity score matching, conditional logistic regression analysis confirmed the results of adjusted analysis. A history of 2 or more previous percutaneous coronary interventions was significantly associated with in-hospital mortality (OR, 1.9; CI, 1.3-2.7; P = .0016) and major adverse cardiac events (OR, 1.5; CI, 1.2-1.9; P = .0019)., Conclusions: Multicenter analysis confirms that a history of multiple previous percutaneous coronary interventions increases in-hospital mortality and the incidence of major adverse cardiac events after subsequent coronary artery bypass grafting. Critical discussion of the treatment strategy in these patients is warranted.

Objectives: Percutaneous coronary intervention of unprotected left main (ULM) stenosis is increasing despite surgical revascularisation being the recommended treatment by the current guidelines. We compared the 30-day and 9-month mortality after ULM stenting with the predicted surgical outcome as determined by the EuroSCORE., Methods and Results: We included 81 consecutive patients who underwent ULM stenting. The patient cohort was divided into a normal risk group (EuroSCORE 5, predicted 30-day mortality 11%). Follow-up examinations were scheduled for one and nine months after the initial PCI. The average EuroSCOREs in the normal- and high-risk group were 3.0 (29 patients, 36%) and 10.0 (52 patients, 64%), respectively. Mortality rates at 30 days were 3% in the normal-risk group and 8% in the high-risk group. Subacute stent thrombosis occurred in 3.4% (three patients) undergoing elective PCI. Major adverse cardiac events during the nine months follow-up were registered in 24% of patients in the normal-risk group, and in 27% of the patients in the high-risk group., Conclusion: Short-term outcome of ULM stenting in our high-risk patients is comparable to surgical outcome predicted by the EuroSCORE. Long-term outcome was less favourable due to a high mortality rate. ULM stenting in patients with low surgical risk could be associated with higher mortality rates compared to CABG because of the unpredictable risk of a fatal stent thrombosis.

Background: Mediastinitis is a rare, but serious complication of cardiac surgery. It has a significant socioeconomic impact and high morbidity. The purpose of this study was to determine pre-, intra-, and postoperative predictors of mediastinitis., Methods and Results: In 1700 consecutive patients, who underwent cardiac surgery in 2001, 49 variables were retrospectively assessed. Forty-five patients (2.65%, 95% CI [1.88; 3.41]) developed postoperative mediastinitis. None of these patients died during their hospitalization. Multivariate analysis identified three of the 49 variables as highly significant independent predictors for the development of mediastinitis: obesity (OR 1.03, 95% CI [1.01; 1.04] p = 0.001), chronic obstructive pulmonary disease (OR 3.30, 95% CI [1.58; 6.88], p = 0.001), and bilateral grafting of the internal mammary artery (OR 3.18, 95% CI [1.20; 8.43] p = 0.02). The model is reliable in terms of its goodness of fit, it also discriminates well. Additionally, univariate analysis identified diabetes mellitus, CCS class and the number of intraoperatively transfused units of fresh frozen plasma as variables with a significant impact., Conclusion: The present study suggests that bilateral IMA grafting, chronic obstructive pulmonary disease and obesity are important predictors of mediastinitis.

Objective: In an international, prospective, observational study, we contrasted adverse vascular outcomes among four countries and then assessed practice pattern differences that may have contributed to these outcomes., Methods: A total of 5065 patients undergoing coronary artery bypass graft surgery were analyzed at 70 international medical centers, and from this pool, 3180 patients from the 4 highest enrolling countries were selected. Fatal and nonfatal postoperative ischemic complications related to the heart, brain, kidney, and gastrointestinal tract were assessed by blinded investigators., Results: In-hospital mortality was 1.5% (9/619) in the United Kingdom, 2.0% (9/444) in Canada, 2.7% (34/1283) in the United States, and 3.8% (32/834) in Germany (P = .03). The rates of the composite outcome (morbidity and mortality) were 12% in the United Kingdom, 16% in Canada, 18% in the United States, and 24% in Germany (P < .001). After adjustment for difference in case-mix (using the European System for Cardiac Operative Risk Evaluation) and practice, country was not an independent predictor for mortality. However, there was an independent effect of country on composite outcome. The practices that were associated with adverse outcomes were the intraoperative use of aprotinin, intraoperative transfusion of fresh-frozen plasma or platelets, lack of use of early postoperative aspirin, and use of postoperative heparin., Conclusions: Significant between-country differences in perioperative outcome exist and appear to be related to hematologic practices, including administration of antifibrinolytics, fresh-frozen plasma, platelets, heparin, and aspirin. Understanding the mechanisms for these observations and selection of practices associated with improved outcomes may result in significant patient benefit.

Neuropathological studies may contribute to the discovery of central nervous system complications after heart surgery and thus help to reduce the incidence of postoperative neurological or cognitive disturbances. We examined the brains of 262 such patients operated for coronary bypass, valve replacement, or heart transplantation. Circulatory disturbances (macro- and microhemorrhages, infarcts, subarachnoid hemorrhages, and hypoxemic brain damage) were present in 128 cases (49%), as the cause of death in 33 cases (12.6%). The infarcts were caused by local arteriosclerosis of brain arteries, arterial emboli originating from the operative sites or myocardial infarctions, or by fat emboli, foreign body emboli or megakaryocytic capillary emboli in rare cases. Inflammatory disturbances were present in 17 cases and consisted of fungal or bacterial septicopyemic changes (12) or of glial nodules (5) as the substrate of a viral or autoimmunencephalitis (Bickerstaff). An incidental finding was Alzheimer's disease in 37 cases (14% of the material) of elderly patients, often associated with cerebral amyloid angiopathy but not as cause of death or cause of macroscopic brain hemorrhage. Since we have conducted an autopsy study, there is a limitation to transfer the documented changes to the total group of post-cardiac surgery patients with neurologic and cognitive deficits. Contrary to some previous reports, histologically overt microembolic phenomena do not seem to play a major role in our material. On the other hand, careful scrutiny revealed non-fatal white matter microhemorrhages of varying frequency in the different groups, especially after valve operations. These as well as the occasional glial nodules, after resorption and microscarring, could well be the cause of slight neurologic and cognitive impairments.

Objectives: To check the hypothesis that continuous magnesium infusion protects the heart from arrhythmias following cardiopulmonary bypass surgery for congenital heart disease., Design: A prospective randomised placebo-controlled study, with patients stratified in three weight groups., Patients and Participants: The study group ( n=65) postoperatively received a magnesium infusion (1 mmol/kg), the control group ( n=66) received placebo. In both groups serum and ionised magnesium values were followed, and all postoperative arrhythmias were documented for 24 h., Measurements and Results: Serum and ionised magnesium in the blood was elevated after the end of bypass (0.54+/-0.15 mmol l(-1) pre-operatively, 0.88+/-0.24 mmol l(-1) postoperatively), where a cardioplegia solution containing magnesium was used. Magnesium values remained at this elevated level in the magnesium therapy group, and decreased to normal pre-operative values within 24 h in controls ( P<0.001). The incidence of postoperative arrhythmias was lower in the study group: 8/65 in the study group and 17/66 in the control group, respectively (chi-squared test, P=0.05). Lower patient weight (32.7 kg versus 22.6 kg), longer cardiopulmonary bypass time (128.7 min versus 87.9 min) and deeper body temperature during extracorporeal circulation (29.2 degrees C versus 32.6 degrees C) were identified as risk factors for postoperative arrhythmias ( P<0.05)., Conclusions: Continuous magnesium infusion effectively reduces the rate of arrhythmias following cardiopulmonary bypass surgery for congenital heart disease and should, therefore, be routinely used.